Laserfiche WebLink
<br />SANAAQUIN <br /> <br />Environmental Health Department <br />- -COUNTY — <br />cotne5s ows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To el-CoMplet01", <br />i . <br />R 0 b ) F-1 R a- \Ai / ") i t i Lic. Plate # /a ti / 53 Business Name <br />Owner/Operator Name KLA pi 19 ) / .5t-vv 4 -/Y - - /4// r f' m ,9-,/,;(g -.5-r :4 4 I4-A' <br />Business Mailing Address 352- ? CfrIpe 1 og ri--.. / <br />City ,,V-6L , LAI r-)7 Stated Zip .7,404, Bus. h. 57 - ‘77--2-Alf. lp. Zc" 07 <br />1,/v )4-R/ -.5utilmr< , hereby state that the above information is current, true and correct to <br />the bet of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must notify-the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature/ l'cin/c(ii <br />repoel /I 7f FA# oo,27193 <br />Address I (02ial HA!" q r\J Fcl_ Bus. Phone .alpfl - itte <br />City Lip4hr ,„p Zip 9$ ;300wner/Operator M47/4V.ey <br />Check all appropriate services provided: <br />"Wastewater disposal 03-compartment sink ",Electrical hook-ups <br />d Solid waste disposal 0 Food preparation riToilet and handwashing <br />0 Hot & Cold water for cleaning 0 Store refrigerated food g "Potable water <br />Ig/Overnight parking aKehicle wash <br /> , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledge and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary own hall no e EHD immediately. <br />Signature <br /> <br />Date <br /> <br />utsJj <br /> <br />16.7 <br /> <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />M Art ) 4 ddc Ku2Mci-erLSJ‘nci oca I A-P-'exe'L' c-k9 <br />ZITO be completed! elit I itettitiNERIOVEVAVO:, <br />Commissary Nameljp44-ht- <br />0 Store dry food/supplies <br />54-4.11--- ien5